Application for FIXED DEFERRED ANNUITY

Transcription

1 Application for FIXED DEFERRED ANNUITY Protective Life Insurance Company Home Office Nashville, Tennessee Administrative Office 1707 N. Randall Road, Elgin, Illinois For Arizona Applicants: We will provide you reasonable factual information about benefits and provisions of the contract within a reasonable time after we receive your written request. You may return the contract to us or the agent through whom it was purchased any time within 10 days of your receipt of the contract or within 30 days: if the contract is issued in replacement of an existing contract, or if you are 65 years of age or older on the date of application. All monies paid will then be refunded to you. Contract # PRIMARY OWNER: NAME: DAY PHONE: ADDRESS: CITY: STATE: ZIP: SSN/Tax ID: DOB: AGE: SEX: M F CITIZENSHIP: U.S.; Resident Alien ( ); Non-Resident Alien ( ) JOINT OWNER: (Where Applicable) NAME: DAY PHONE: ADDRESS: CITY: STATE: ZIP: SSN/Tax ID: DOB: AGE: SEX: M F CITIZENSHIP: U.S.; Resident Alien ( ); Non-Resident Alien ( ) ANNUITANT: (If different from Primary Owner)(Must be a natural person) NAME: DAY PHONE: ADDRESS: CITY: STATE: ZIP: SSN/Tax ID: DOB: AGE: SEX: M F CITIZENSHIP: U.S.; Resident Alien ( ); Non-Resident Alien ( ) BENEFICIARY DESIGNATION (If there is no surviving Owner): PRIMARY CONTINGENT: PERCENTAGE: RELATIONSHIP (to Owner): Spouse Nonspouse SSN/Tax ID: DOB/Trust date: PRIMARY CONTINGENT: PERCENTAGE: RELATIONSHIP (to Owner): Spouse Nonspouse SSN/Tax ID: DOB/Trust date: ADDITIONAL BENEFICIARIES Use 'REMARKS' section, below. INITIAL PURCHASE PAYMENT (check payable to Protective Life Insurance Company): WITH FUNDS FUNDS WILL FOLLOW (minimum $2,000) INTEREST RATE PERIOD AND OPTIONAL RETURN OF PREMIUM: Please select one interest rate period and one Return of Premium option. 1 Year Interest Rate Period 2 Year Interest Rate Period YES, I elect the Return of Premium Option 4 Year Interest Rate Period 6 Year Interest Rate Period NO, I decline the Return of Premium Option TAX QUALIFIED STATUS: Non-Qualified ROTH IRA (Conversion Year, if applicable) 1035 Exchange Traditional IRA Other - REMARKS: $ CONTRIBUTION FOR TAX YEAR $ TRUSTEE TRANSFER $ ROLLOVER FROM An annuity contract is not a deposit or obligation of, or guaranteed by any bank or financial institution. It is not insured by the Federal Deposit Insurance Corporation or any other government agency. Original Representative First Copy Owner P-1405 Secure II Fixed Annuity with Optional Return of Premium 6/17

2 Warnings, Notices and Statements Arkansas, District of Columbia, Kentucky, Louisiana, Maine, New Mexico, Ohio, Pennsylvania, Rhode Island and Tennessee Fraud Warning - Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. Colorado Fraud Warning - It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory agencies. FLORIDA FRAUD WARNING - ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER, FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. Maryland Fraud Warning - Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Michigan Fraud Warning - Any person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer, as determined by a court of competent jurisdiction, is guilty of a crime. New Jersey Fraud Warning - Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Oklahoma Fraud Warning - WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Washington Fraud Warning - It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. Will any existing annuity contract or life insurance policy be replaced or will values from another annuity contract or life insurance policy (through loans, surrenders or otherwise) be used to make purchase payments for the contract applied for? NO YES Do you have any existing annuity contracts or life insurance policies? NO YES If Yes, Company Name: NOT INSURED BY ANY GOVERNMENT AGENCY NO BANK GUARANTEE NOT A DEPOSIT I/We understand this application will be part of the annuity contract. I/We have read, agree to and affirm the information above and on the reverse side to be true and correct to the best of my/our knowledge and belief. The Company will treat my/our statements as representations, not warranties. The Company may accept instructions from any Owner on behalf of all Owners. Signed at CITY STATE DATE OWNER SIGNATURE JOINT OWNER SIGNATURE (if applicable) ANNUITANT SIGNATURE (if other than Owner) Federal law requires the following notice: We may request or obtain additional information to establish or verify your identity. SELLING AGENT REPORT: To the best of your knowledge, will any existing annuity contract or life insurance policy be replaced or will values from another annuity contract or life insurance policy (through loans, surrenders, or otherwise) be used to make purchase payments for the contract applied for? NO YES Does the applicant have any existing annuity contracts or life insurance policies? NO YES If Yes, Company Name: Type of unexpired government-issued photo I.D. used to verify the applicant's identity? # I certify that the information provided by the owner has been accurately recorded; no written sales materials other than those approved by the Company were used; and I have reasonable grounds to believe the purchase of the contract applied for is suitable for the owner. AGENT SIGNATURE AGENT NAME PRINTED AGENT TELEPHONE NUMBER DATE AGENCY NAME FLORIDA LICENSE# (FLORIDA CONTRACTS ONLY) AGENT STANDARD ID# P-1405 Secure II Fixed Annuity with Optional Return of Premium 6/17 Select Commission Option: A B C

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